Professor Peter A. Lio reviews topical therapies for atopic dermatitis for Medscape.
Dr. Peter Lio, it’s great to have the opportunity to discuss topical treatments for adults with atopic dermatitis with you. What are the typical signs and symptoms of atopic dermatitis that can help guide treatment decisions?
This is a difficult question for a disease that affects up to 10% of adults and perhaps up to 20% of children with a complex etiopathogenesis.(1,2) I would say the typical scenario includes a patient with mild or moderate illness characterized by itchy patches in the head, neck, and/or flexures. I have patients who haven’t had a normal night’s sleep in a decade, so the burden of atopic dermatitis can be enormous. The diagnosis is made on the basis of the presence of one or more symptoms, including pruritus, erythema, scaling, xerosis, edema, excoriations, oozing and crusting or lichenification, and the exclusion of other possible diagnoses. This can be very difficult, however, because allergic contact dermatitis and other conditions can mimic atopic dermatitis.(3,4) For example, I have been referred to patients who actually had cutaneous T-cell lymphoma, scabies infestation, zinc deficiency, and secondary infection associated with the herpes virus or herpes virus. Staphylococcus. The first step once the diagnosis is confirmed is to have an idea of the type of atopic dermatitis based on the history of its appearance, when it worsened, the extent and distribution of the lesions, triggering factors and medications and approaches used. tent.(2,3) It truly is a journey that can have many twists and turns, especially for patients with more serious illness.
The availability of new topical treatments over the past decade is remarkable. What is the first line of topical treatment in adults with atopic dermatitis?
I would like to emphasize the importance of patient education: our goal is to get the disease under good control and keep it there, but we cannot cure it. It is crucial to communicate this. Patients should be able to avoid irritants and support their skin by using a good moisturizer. I see great results with lifestyle changes and over-the-counter therapies.(5) There is also good evidence that a detailed written treatment plan improves outcomes, and I consider this to be the most important intervention. The next step on the therapeutic ladder is so-called reactive therapy, which typically consists of low-to-medium potency topical corticosteroids (TCS) in patients reporting occasional flare-ups despite initial interventions. TCS are very safe when used correctly, and they are cheap and reliable.(2,3) Although they are relatively safe, I think it is important to monitor relatively closely and be cautious about overusing them. Often you can control the disease with TCS alone, but three scenarios can occur: (1) inability to control the disease, (2) inability to keep it safely away, or (3) ) the patient cannot adhere to the treatment even if it works. The second most common scenario is when patients use, for example, triamcinolone almost every day for 2 months or after their disease improves and they stop TCS, it comes back with a vengeance. In all three scenarios, the next step is a proactive approach, which usually means using a more potent steroid to improve symptoms along with maintenance treatment, ideally with a non-steroidal medication, although steroids low power can also be used. So, you can use a nonsteroidal agent such as a topical calcineurin inhibitor (TCI) or a phosphodiesterase 4 (PDE-4) inhibitor like crisaborole daily on the remaining areas and hot spots to prevent flare-ups. Although not explicitly approved by the United States Food and Drug Administration (FDA) for use in this manner, there is a robust literature on this approach, which is arguably well within the “letter of law” in terms of approved use. .
Should primary care providers prescribe a topical PDE-4 inhibitor and a topical Janus kinase (JAK) inhibitor, or is this an indication to refer the patient to a dermatologist?
I am wise enough to say that there is no right answer to this question. There is a range of comfort in primary care, and it is entirely normal to refer a patient with even the slightest rash to a dermatologist, especially considering how difficult diagnosis can sometimes be. There’s no shame in that! Some primary care clinicians are extremely knowledgeable about skin diseases and tend to refer to them more as a last resort. Ruxolitinib, a topical JAK inhibitor, has been approved for short-term, non-continuous treatment of mild to moderate atopic dermatitis. It is well tolerated, but patients need good counseling as black box warnings include infections, cancer, cardiovascular events and thrombosis.(6) The most common adverse event related to topical treatment is skin atrophy or thinning and stretch marks associated with TCS, but there is also much debate about topical steroid withdrawal syndrome, although it remains somewhat controversial.(7) Side effects of TCI are primarily skin heat and burning, although the FDA issued a black box warning regarding the theoretical risk of cancer in 2006(8); it also requires good advice to help alleviate concerns.
What is the evidence in favor of alternative medicines in atopic dermatitis?
As we advance our knowledge of the etiopathogenesis of atopic dermatitis, many alternative treatments have been tested. I have devoted a large part of my career to this field of study. These approaches may be valuable complementary therapies to more conventional guideline-based approaches. Stress management techniques appear to be beneficial, which makes sense given the effect of stress and poor sleep on the microbiome and skin barrier. Habit reversal therapy (HRT) can help patients avoid scratching by replacing it with light tapping or playing with beads, for example.(ten) It’s quite good, simple and very safe. You can find great resources about HRT online. Regarding topical treatments, I’m a big fan of sunflower oil, which can actually induce endogenous ceramide production and also has an anti-inflammatory effect, probably via the NF-kB pathway.(11) Coconut oil(8) has antimicrobial properties against Staphylococcus colonization(12); it is also a good emollient and very soothing.(13) Topical vitamin B12 has had two fairly impressive trials showing it to be a superior vehicle in the treatment of atopic dermatitis. There are also good studies on hemp seed oil taken orally.(14) In my practice I have also used acupuncture and acupressure with good results.(15) There is growing evidence to support the integration of these integrative approaches in the treatment of atopic dermatitis.
Do you recommend a scoring tool to assess treatment effectiveness?
What concerns me about some scoring tools is their limited ability to assess a chronic illness that may seem good one day and very serious the next. Most of these scoring tools are not useful in clinical practice; they are burdensome and may underestimate the severity of the disease, with possible implications for treatment and treatment coverage by health insurance companies. I find the Atopic Dermatitis Screening Tool (ADCT), with six questions that can be asked in 45 seconds, to be an excellent tool for informing treatment decisions.(16) In fact, it’s a self-assessment tool that allows patients to answer these questions right before their appointment. If the score is 7 points or more or if there is an increase of 5 points or more from a previous assessment, this indicates worsening of the disease. To ask a better question: instead of “How serious are you?” » ask: “Have we managed to control your eczema?” For me, that’s really the only question that matters.
Are there any upcoming therapies on the horizon for atopic dermatitis that are expected to change practice in the near future?
It’s amazing how many new therapies are currently being developed targeting inflammation, itching, and the skin barrier. I would highlight OX40 inhibitors acting on the pro-inflammatory OX40-OX40L pathway(17); topical roflumilast, a PDE-4 inhibitor; and a host of new JAK inhibitors. There is a powerful new treatment for itching: nemolizumab, a biologic agent that inhibits IL-31.(18) Skin barrier repair therapies are also evolving rapidly with many new ideas, including moisturizers containing ceramides or L-arginine. The microbiome is an important area with emerging probiotics, prebiotics, synbiotics and parabiotics.(19,20) I participated in trials on a probiotic spray, Nitrosomonas, with promising results. We can expect many new treatments for atopic dermatitis.
That’s exciting! Thank you for this comprehensive review.
THANKS.
